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Venerino Poletti Ospedale Morgagni Forlì

FOCUS ON PIRFENIDONE. Venerino Poletti Ospedale Morgagni Forlì. Conflicts of Interest. Member of the Advisory Borad of Intermune. PIRFENIDONE & LUNG *has antifibrotic and anti-inflammatory anti-oxidant properties in various in vitro systems and animal models of pulmonary

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Venerino Poletti Ospedale Morgagni Forlì

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  1. FOCUS ON PIRFENIDONE Venerino Poletti Ospedale Morgagni Forlì

  2. Conflicts of Interest • Member of the AdvisoryBorad of Intermune

  3. PIRFENIDONE & LUNG *has antifibrotic and anti-inflammatory anti-oxidant properties in various in vitro systems and animal models of pulmonary fibrosis, *attenuates fibroblast proliferation, production of fibrosis-associated proteins and cytokines, and the increased biosynthesis and accumulation of extracellular matrix in response to cytokines such as transforming growth factor-β.

  4. PHARMACOKINETICS Pirfenidone is administered orally. Though the presence of food significantly reduces the extent of absorption the drug is to be taken after food, to reduce the nausea and dizziness It is –around 60%- bound to plasma proteins, mainly to albumin Up to 50% is metabolized by hepatic CYP1A2 enzyme system to yield 5-carboxypirfenidone, the inactive metabolite Almost 80% of the administered dose is excreted in the urine within 24 hours of intake

  5. Pirfenidone: the past • 54 IPF patients • Deterioration with steroids ± I°S • TLC 58 ± 16 % • DLCO 34 ± 17 % Pirfenidone: 40 mg/kg (maxi 3600 mg/j) Stop CS and I°S within 8 weeks (Raghu, AJRCCM 1999;159:1060)

  6. Pirfenidone, 24 months TLC FVC DLCO SpO2 O2 (Raghu, AJRCCM 1999;159:1060)

  7. FVC decline Grouped analysis % patients with ΔFVC > 10% • Progression free survival RR=0.74 P=0.025 • Distance 6MWT Δ=24m P=0.009 • Positive trend for mortality reduction (Noble, Lancet 2011;377:1760)

  8. Pirfenidone • Pirfenidone: • Antifibrotic, antioxidant, anti-TNF • Different experimental models :heart, lung, kidney fibrosis • A series of four randomized controlled studies: (>1100 patients)

  9. At Week 52, 16.5% of patients in the pirfenidone group experienced an FVC decline of 10% or more or death, compared with 31.8% in the placebo group, representing a 47.9% reduction in the proportion of patients who experienced a meaningful change in FVC or death.  Additionally, at Week 52 the data demonstrated that 22.7% of patients in the pirfenidone group experienced no decline in FVC, compared with 9.7% in the placebo group, representing a 132.5% increase in the proportion of patients whose FVC did not decrease between Baseline and Week 52. PFS is a measure of time before death or a disease-progression event.  A PFS event was defined in the protocol as any of the following: death, percent predicted FVC decrement of 10% or greater or 6MWD decrement of 50 meters or greater.  In ASCEND, pirfenidone reduced the risk of death or disease progression by 43% compared to placebo (Hazard Ratio [HR]=0.57; 95% confidence interval, 0.43-0.77; p=0.0001). Ascend trial: PRESS RELEASE

  10. PIRFENIDONE IN IPF:PRACTICAL ISSUES

  11. Posology and Administration: METHOD OF ADMINISTRATION

  12. Posology and Administration: DOSE TITRATION

  13. PATIENTS ASSESMENT BEFORE PIRFENIDONE TREATMENT: LABORATORY WORK-OUT • BLOOD CELL COUNT • LIVER FUNCTION TESTS -> SEVERE HEPATIC IMPAIRMENT IS A CONTROINDICATION – CAUTION IF MILD-MODERATE HEPATIC IMPAIRMENT • SCREENING FOR HEPATITIS B AND C -> if positive CAUTION SHOULD BE USED • RENAL FUNCTION TESTS -> SEVERE RENAL IMPAIRMENT (Cl creat <30%) IS A CONTROINDICATION

  14. PATIENTS ASSESMENT BEFORE PIRFENIDONE TREATMENT: CONCOMITANT MEDICATIONS Fluvoxamine is the ONLY CONTROINDICATED DRUG Patientstaking CYP MODERATE AND STRONG INHIBITORS should be monitoredclosely CYP1 A2 INHIBITORS Amiodarone Propafenone Ciprofloxacin CYP2 C9 INHIBITORS Amiodarone Fluconazole CYP2 D6 INHIBITORS Paroxetine Fluoxetine CYP2 C19 INHIBITORS Chloramphenicol The concomitantuseof CYP1 A2 INDUCERS mayresult in decreased plasma levelsofPirfenidone CYP1 A2 MODERATE INDUCER Omeprazole CYP1 POTENT INDUCER Rifampicin

  15. Posology and Administration: DOSE ADJUSTMENT FOR SAFE USE

  16. Posology and Administration: DOSE ADJUSTMENT FOR SAFE USE

  17. Posology and Administration: DOSE ADJUSTMENT FOR SAFE USE ALT, AST and BILIRUBIN should be monitored MONTHLY FOR THE FIRST 6MONTHS AND THEN EVERY THREE MONTHS.

  18. Posology and Administration: DOSE ADJUSTMENT FOR SAFE USE

  19. PIRFENIDONE:SUMMARY • Pirfenidone requires a diagnosis of definite IPF, mild-moderate stage. • Take sufficient time for patient counseling, plan subsequent visits and give the patient a number to stay in contact • Dosage adjustments and temporary interruptions are sufficient to resolve the majority of mild to moderate side effects • Severe drug reactions are unusual (10%) and resolve without sequelae after drug discontinuation • Pirfenidone significantly reduce the risk of disease progression • IPF is still a lethal disease, but now is curable

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